Ambetter SilverSummit

Ambetter Balanced Care 4 + Vision + Adult Dental

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $7,200 Family: $14,400 Per Person: $7,200
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,200 Family: $14,400 Per Person: $7,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $30 Copay
Specialist	Standard: $60 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $50 Copay
Non Preferred Brand Drugs	Standard: No Charge after deductible
Generic Drugs	Standard: $13.80 Copay
Specialty Drugs	Standard: No Charge after deductible

Inpatient Coverage

Hospital Services	Standard: No Charge after deductible
Inpatient Services	Standard: No Charge after deductible

Emergency and Urgent Care

Emergency Room

Standard: No Charge after deductible

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